The example given earlier was that of a colonoscopy. Same applies to routine care or elective imaging like back or knee MRIs and labwork. Dont just go where your orthopedic surgeon sends you, check out the prices, get estimates, negotiate. You wont have much luck with hospitals or large clinics in that regard, but any place that has an actual 'owner' will work with you on price. Cash is king, I have gotten payment for entire surgeries 'cash on the barrel'. For any provider that participates in medicare, the medicare allowable is pretty much the floor of what they are allowed to take by law.
But yes, if you end up in the ER you are at the mercy of the hospital and the different provider groups (ER, rads, cards, ortho) that provide coverage for that hospital. There have been some cases of 'doctors behaving badly' who attempt to squeeze unreasonable amounts out of patients who wandered into the ER. A cardiologist in NJ charged $30,000 for a simple ultrasound exam, some OB/GYNs tried to get $50,000 in surgical fees for an out of network cesarean section.
Generally, it is a good idea to get your health insurance with the market leader in a community and to familiarize yourself with their provider directory. If you know that the cardiology group of Dowie Cheatam and Howe PC is non-par with your insurance, then dont go to the cats and dogs hospital they cover. Unless you are in some authoritarian regime like NYC, you are in control where the ambulance brings you.
Now if you sign up for some cheap-ass out of state HMO just because their copay is $20 instead of $35, dont be suprised if all your emergency care ends up being out of network.
Many hospitals require all provider groups that provide emergency coverage to contract with all the insurance plans the hospital participates in. Call up the hospitals in your area and inquire whether they do that, if they don't, tell them that you wont use their services.
Is this the greatest system, of course not. If I provide you a service that I think is worth $125, what I want to do is to take $125 from you when you leave my office and leave it up to you to get the money back from your insurance. The way it works right now, in order to get my $125, I send your insurance company a bill for $300, 89 days later they send me an explanation of benefits that requires me to write off $200 and pay me $75. I then need to spend money on postage and printing to collect the $25 coinsurance from you. In the end I get my money 3-6 months late and 20% below what I calculated. Yes, there is a better way, and it is not the horse-manure we get shoveled from the current regime.
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